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PARENTERAL NUTRITION HOME-STARTS

People unable to use their
gastrointestinal (GI) tract due to intestinal failure require parenteral
nutrition (PN). PN, the administration of IV nutrients, is a potentially
lifesaving ther­apy that, when required long-term, can be administered safely
in the home to allow people to live highe-quality lives.

Some clinicians believe PN
should always be started in a hospital setting where patients can be closely
monitored to avoid potential complications such as refeeding syndrome, which
causes electrolyte imbalances of serum phosphorous, potassium, and magnesium
that can potentially lead to heart failure or other life-threatening
conditions.

However, many home infusion
companies have safely and successfully started PN at home in patients with mild
to moderate electrolyte abnormalities by correcting these electrolytes before
PN infusion.This
allows the patient to be more comfortable and avoids the risk of possible expo­sure
to hospital-acquired infections while reducing overall health care costs.

One of the earliest reports on
transitioning PN from the hospital to the home was documented 40 years ago.Due
to technological advances in access devices, infusion pumps, home care agency
creation, and reimburse­ment strategies, select patients have been starting PN
in the comfort of their homes for the past 20 years.In fact, data spanning the last 10 years have
estimated that 39,000 patients receive PN at home each year.Home-start PN can save nearly $2,000 per day in
healthcare costs compared with receiv­ing IV feeding in the hospital.

Whether a patient begins PN in
the hospi­tal or at home, a knowledgeable interdisciplin­ary team must develop
a care plan with the patient that includes the indication for home PN, the
approximate length of time the therapy is needed, the end point of therapy, and
nutri­tional goals.

This article will take a closer
look at home-start PN and evaluate its benefits in compari­son with
hospital-start PN as well as discuss the role dietitians can play in preparing
the patient and family for PN care in the home setting.

Evaluating the Home Environment

Once a physician determines a
patient is a good candidate for home PN, a home infusion nurse first assesses
the patient’s home environment for cleanliness, sanitary water supply, elec­tricity,
refrigeration, adequate storage space for supplies, and telephone access.The
nurse also assesses whether the patient or caregiver is capable of
administering home PN ther­apy and verifies insurance coverage. If the patient
is in the hos­pital, a social worker, PN nurse, and nurse case manager meet
with the patient and family at the bedside to assess the home environment and
insurance coverage for home PN care.

Home PN Education

Once it’s considered safe to
administer home PN, quali­fied healthcare nurses begin educating the patient
and family about what it entails. The patient or a family member is chosen as
the primary caregiver who must demonstrate competence in preparing and
administering PN, which includes infection control, caring for the vascular
access device, connecting and disconnecting the IV tubing, safely incorporating
additives, and properly storing supplies.For hospital-start PN patients, the PN nurse
educates the patient and family at the bedside, and a visiting nurse contin­ues
the instruction at home.

All patients receive three consecutive days of lessons
in the home. Once the home infusion nurse determines the pri­mary caregiver can
implement PN procedures, the nurse will make weekly visits.

Advantages of Hospital-Start PN

Most patients discharged from
the hospital on PN weren’t admitted specifically to start PN but for unrelated
medical or surgical reasons that resulted in the need for home PN care.

Due to safety concerns,
clinicians often prefer hospital-start PN. High-risk patients who would benefit
from hospital-start PN include infants, the elderly, IV drug users, patients
with fluid and electrolyte disorders, those with uncontrolled diabetes or major
organ dysfunction, or those at high risk of refeeding syndrome.

Replacing fluid and
electrolytes before initiating PN and then starting PN with a low carbohydrate
load can prevent refeeding syndrome. Rex Speerhas, RPh, BCNSP, a clinical
nutrition specialist at the Cleveland Clinic, says, “The patient can be treated
much more promptly and effectively in the hospital setting with frequent
intravenous electrolyte supple­mentation.” The bedside nurse and primary care
physician also can closely monitor the patient.

Another concern is
hyperglycemia, the most common side effect in preparing a patient for cyclic
home PN.“When
a patient is initiated in the hospital setting, blood glucose levels can be monitored
much more frequently, thus episodes of hyperglycemia can be immediately treated
with insulin or avoided completely,” Speerhas says, adding that to achieve the
same quality of care, close monitoring in the home set­ting would require the
presence of a healthcare professional around the clock. The testing supplies
needed would quickly become very costly to the patient.

The hospital dietitian’s role
in preparing the patient for home PN involves stabilizing and cycling the PN
formula by monitoring daily vital signs, electrolytes, glucose levels, intake
and output records, and weights. This usually takes three to six days to
complete. PN is started at full protein needs with one-half of the dextrose
load infused continuously over 24 hours. Lipids usually are given separately.
Shortening the infusion time by four hours each day over three consecu­tive
days or six hours each day for two consecutive days can cycle PN from 24 to 12
hours. In stable, select patients, PN can be cycled from 24 to 12 hours over one
day.

Advantages of Home-Start PN

While hospital-start PN has its
advantages, home-start PN also has its benefits. Home-start PN enables patients
to learn about PN in the comfort of their home plus they have fewer hospital
expenses and don’t have to worry about hospital-acquired infections.10 The
decision to initiate PN in the home depends on patients’ clinical stability,
whether they have a need for PN, whether a nurse can evaluate them in their
home, and whether a caregiver can safely adminis­ter the therapy.

Patients who can receive home
PN care are those who either don’t have a chronic illness or have a chronic
illness that’s well controlled, such as cancer, HIV, hyperemesis gravidarum, or
GI disorders; those with bariatric surgery complications; or those with failed
enteral nutrition.

Many home infusion companies
that provide home-start PN services have experienced dietitians, nurses, and
phar­macists working for them who can offer quality care to patients and have a
track record of successfully initiating PN in the home, bypassing hospital
admission.

Walgreens Infusion Services, the nation’s largest infu­sion
provider, initiates home PN with at least one patient almost every day.
According to Noreen Luszcz, RD, MBA, CNSC, Walgreens’ nutrition program
director, the key to the company’s success is its multidisciplinary team
approach, slow progression of starting PN, and ongoing communica­tion with the
team, patient, and physician. Slow progression means that macronutrients,
especially dextrose, are started at a reduced concentration to prevent
complications such as hyperglycemia or electrolyte imbalances.

Once Walgreens receives a
referral from a physician’s office or clinic, a dietitian and a nurse become
actively involved in the initial home visit. The dietitian completes a
comprehensive nutrition assessment and determines needs and formula
recommendations.

Choosing appropriate patients
for home-start PN is essential. Luszcz reports that high-risk patients, such as
those with uncontrolled diabetes, high GI losses, or multi­ple organ failure,
usually are referred to hospital-start PN. When beginning PN in the home,
however, Luszcz says Wal­greens’ patients begin with reduced protein, dextrose,
and lipids infused over 24 hours. Daily weights, lab data, and intake and
output records are closely monitored.

Once the patient is stabilized,
which can take several days, PN is slowly increased to provide the full amount
of macro­nutrients. PN is reduced to 18 hours and eventually to eight to 12
hours once the patient is stabilized on full PN. Some home infusion companies,
such as ThriveRx, start low-calorie PN over 12 to 18 hours at a reduced rate
for younger, stable patients, according to Donna Kloth, RN, CRNI, CNSC, a
nutrition liaison with ThriveRx. “By carefully monitoring the patient, we
slowly advance the PN formulation to goal, which usually takes a week,” she
explains.

To prevent refeeding syndrome,
home infusion companies usually have protocols that involve administering
replace­ment fluids and electrolytes in the home before starting PN. In one
study, Walgreens showed that patients at risk of refeeding syndrome can safely
begin home PN, eliminating the need for hospital admission.In this small, retrospec­tive study, 15 high-risk
patients were started on 25% of dex­trose needs for the first three to four
days. Once the patients were stabilized, 50% of dextrose needs were given for
another three to four days. Researchers closely monitored lab results, and
patients reached their PN goal needs.

Safe Alternative

Patients have been started
safely on PN in the hospital setting and at home for many years. The key to
this success has been the experience of knowledgeable interdisciplinary
healthcare teams consisting of physicians, dietitians, nurses, and pharmacists.
With the advances in standards of care, equipment, and specialized home
infusion services, patients can start IV nutrition at home, allowing for
continued daily activities and increased quality of life.